Prior Authorization Call Center

When a claim returns the NCPDP error code 75 ("Prior Authorization Required") and the additional message, "Prescriber call PA Texas at 1‐877‐728‐3927 (1‐877‐PA‐TEXAS)", then only the prescribing physician or his/her designated staff representatives can request the prior authorization.  There are two options on how to request the prior authorization:

• By phone: call the Texas Prior Authorization Call Center at 1-877-PA-TEXAS (1-877-728-3927) for preferred drug and/or clinical prior authorization.
• Online: through PAXpress (registration instructions).  Note: this feature is only available for non-preferred drug prior authorization requests at this time.

Approved requests for prior authorization will be valid for one year.  Prior authorization requests for non-preferred agents will not be handled via the Pharmacy Resolution Help Desk and pharmacies should not contact Vendor Drug to verify the prior authorization rejection.  In some cases, Vendor Drug will already have claim data that indicates that the client has met the prior authorization criteria for the non-preferred drug requested. In those cases, the prescription will be prior authorized without the necessity of a phone call.

Claim submission

Submitting Claims for a preferred drug at the point-of-sale:

If the claim is for a preferred agent the point-of-sale transaction will be approved, the drug claim will pay, and no further action will be required. The pharmacy should fill the prescription per standard store or facility procedures.

Submitting Claims for a non-preferred drug at the point-of-sale:

If a prior authorization is not on file, has expired, or the claim does not meet the PDL approval criteria, the claim will be denied at point-of-sale. The recipient should contact his or her prescriber's office since additional information may be required for evaluation of the prior authorization before any approval can be issued.

Requesting a Prior Authorization for a non-preferred drug

The following information is required by the Texas Prior Authorization Call Center in order to quickly assess the prior authorization request. Requests submitted with missing information will not be assessed until that information is provided.

Client-specific information:

• Medicaid Cardholder ID number
• Client Name
• Client Date of Birth
• Reason for requesting override for a non-preferred drug

Prescriber-specific information:

• Physician Name (or name of delegating physician)
• State License number

Claim-specific information:

• Requested drug and strength
• Days supply
• Number of refills

Call Center Determination

If the Texas Prior Authorization Call Center approves the prior authorization, the patient can return to their pharmacy to obtain the prescription. The drug claim will pay and no further action will be required. Approved requests for prior authorization will be valid for one year.

If the Texas Prior Authorization Call Center denies the request, the physician's office will be notified immediately. The prescriber has the option of prescribing a different treatment course that does not require prior authorization or submitting the Request for Reconsideration form.

Emergency Supply

In cases where a prior authorization is medically necessary the Texas Vendor Drug Program will allow for a 72-hour emergency supply of a non-preferred drug.

Request for Reconsideration

The prescriber may request reconsideration if the Texas Prior Authorization Call Center denies a prior authorization request. If a request for prior authorization is denied after going through the call center process, the call center staff will inform the physician that he has the right to request reconsideration of the decision rendered. The call center representative will provide the physician with the steps to request reconsideration of a prior authorization decision. The Prior Authorization Request for Reconsideration form is required to initiate the request and provides a brief description of the steps for reconsideration.

Please fax the Request for Reconsideration Form to the Texas Prior Authorization Center at 1-866-617-8864. This fax number is only to be used for reconsideration requests after the call center has denied a phone request. Initial prior authorization requests will not be accepted via fax.

Once a prior authorization request goes through the call center process and is denied, no verbal requests for reconsideration can be accepted. Supporting documentation should include the following:

• Request for Reconsideration form.
• A copy of the client's applicable medical records or lab results documenting the medical reason for the treatment.
• If applicable, supporting peer-reviewed literature for the treatment.

Determinations of the Request for Reconsideration form will be mailed to the requesting prescriber and client. If the Request for Reconsideration form is denied, the client's letter will include information on the Texas Vendor Drug Program appeal process.

Managed Care Resources for Prescribers

For Medicaid clients that obtain prescription drug benefits through a managed care plan:

• Prior Authorization Call Center phone numbers may vary by MCO.
• Prior Authorization is required for non-preferred drugs and drugs subject to clinical PA edits.  MCOs/PBMs may implement any of the Vendor Drug Program’s clinical PAs, but no more.
• All active drug prior authorizations have been sent to MCOs to reduce/eliminate the need for prescribers to request a new PA for their clients that are already authorized.
• MCOs must notify the prescriber’s office of a PA approval/denial within 24 hours of the time of the request.